De-Regionalizing Alberta

The Road to Reform or Collateral Political Damage?
And then there was one.

by Steven Lewis

Last Wednesday (May 14, 2008), 12 boards governed Alberta’s 9 health regions, and the province’s mental health, cancer, and alcohol and addictions programs. A day later they were all replaced by the Alberta Health Services Board (AHSB). Alberta is the second province to eliminate RHA boards – PEI (population 140,000) was the first. New Brunswick is down to two. The Alberta solution is nothing if not Canadian: when in doubt, restructure.

Why this, and why now? Recent Alberta politics explain the timing. Premier Ed Stelmach was the surprise winner in the Conservative leadership race last year over heir apparent (and previous Calgary RHA Board Chair) Jim Dinning. Widely expected to suffer serious electoral losses in the recent election, Stelmach won a massive majority. This conferred a license to make a clear and dramatic statement as a means
of putting a new face on government and bidding a final adieu to the Klein-Calgary era.

The why is more interesting. Regionalization as originally conceived was intended to devolve authority from the provincial level while consolidating it at the local level. In no province was devolution as thoroughgoing as envisioned. Political accountability proved difficult to devolve, so governments continued to have to answer for alleged regional missteps. Over the years most provinces have repatriated authority from the regions, retaining control over major decisions such as facility closures and earmarking funds for specific purposes. But RHA boards do experiment and innovate, reach out across sectors, have mechanisms for responding to local concerns and preferences, and advocate for their regions.

So what, in the government’s view, is the trouble with regionalization? In April Health & Wellness Minister Ron Liepert said that a new governance model was needed to improve management. Perhaps the new regime sees the regions as vocal irritants always clamouring for money. Perhaps it was an accumulation of perceived sins, from the instrument sterilization cock-ups in East Central to the very public complaints of underfunding by the Calgary RHA leadership prior to and after the election. Structural reform does not guarantee improved access, better quality, or greater efficiency. Moreover, restructuring takes its toll on leadership and creates anxiety among the troops. It succeeds only when it is part of a coordinated, substantive plan to change the system’s culture, incentives, and accountability.

The creation of the AHSB is the first of a promised three stages of changes to be announced by December 15, 2008. The most concrete commitments thus far are to train more doctors, extend the ban on trans fats in restaurants and get rid of junk food in schools. Whatever the merits of these measures, they are hardly transformational, and none requires taking regionalization apart.

That leaves de-regionalization and its prospects for success. The key questions are:
• Will the promised Community Health Councils be acceptable substitutes for the RHA boards or dismissed as toothless imitations of the real deal? They are to be appointed by the AHSB, raising obvious questions about their independence and capacity to advocate and criticize. British Columbia had a two-tier system in the 1990s, with local community councils mandated to advise the RHA boards. The public had more connection to and confidence in the community councils than the RHA. The government eliminated the tension by getting rid of the community councils.
• What will become of the population health agenda? Reducing health disparities is intersectoral work that takes place at the neighbourhood and community level. One of the unsung triumphs of regionalization has been the education of boards about the non-medical determinants of health and the importance of addressing the root causes of ill health. Can a single provincial board even begin to understand and pursue a population health agenda in the face of the predictable preoccupation with access, wait times, drugs and technologies? Will the system stake its future on a highly
medicalized, technology-focused view of health? Who will champion prevention and health promotion, and back up rhetoric with dollars?
• How will the voices of the marginalized be heard? It’s daunting enough to get the attention of an RHA board, let alone a single provincial authority working out of Edmonton.
• If the model retains regions as administrative units, how much authority and flexibility will accrue to the executives? To what extent will they be able to reallocate funds and experiment with new approaches? Existing CEOs, several of whom have national and international reputations, have been given until April 2009 to find other work. Will this capacity find meaningful roles in the new era or will the province find itself with a severe executive talent shortage?
• The new board reports directly to the Minister. Will the Minister (and the ministry) set out a broad set of expectations and accountabilities and let the board operate with considerable autonomy – almost like a Crown Corporation – or will the leash be short? Will the power lie with the AHSB or with the Minister and Deputy?

All should clarify in the coming months. The first move shows no lack of courage: poking a stick in the eye of 125 politically well-connected board members and the communities they represent is a calculated act of disharmony. If there is leftover boldness to apply to the substantive issues, there are some intriguing possibilities. Imagine the AHSB with a mandate to achieve:
• A fully functional, interoperable, standardized electronic medical record within 2 years.
• A health human resources plan that optimizes the roles of all providers, with expanded roles for nurses, pharmacists, and therapists.
• The full integration of physicians into the system with a focus on primary health care.
• The removal of all of the perverse incentives in the system that drive up costs and stand in the way of equitable, high quality care.
• A brave, evidence-based, cost-effective approach to drug purchasing and prescribing.
• A real reduction in health disparities between the well-off and the disadvantaged.

In a jurisdiction truly committed to reform, the restructuring would be the warmup act to a genuine transformation agenda. Alberta’s health regions have arguably been leaders in quality improvement, health information technology adoption, and primary health care renewal. With the stroke of a pen a great deal of innovation capacity and experience has been cast aside. Nothing in the public communiqués to date suggests that anyone has thought very deeply about the risks and consequences of the dismantling. The challenge for the government and the AHSB is to get out of the gate with some creative policies and progressive decisions.

Without some early and tangible wins, the memory of May 15, 2008 may linger longer and deeper in the public consciousness than its architects ever imagined.
______________
Steven Lewis is President, Access Consulting Ltd., Saskatoon, Adjunct Professor of Health Policy, University of Calgary & Simon Fraser University and a member of the editorial advisory board for the journal Healthcare Papers | Steven.Lewis@shaw.ca

Electronic Med Records Are Worth the Privacy Risk

From the Wall Street Journal Blog of November 29, 2007, 9:06 am
Poll: Electronic Med Records Are Worth the Privacy Risk
Posted by Jacob Goldstein

On the subject of electronic medical records, regular folks appear to agree with the health-wonk elite.

Yes, electronic records make it tougher to keep patients’ records private, most people said in a new poll from the WSJ Online and Harris Interactive. But the risk is worth it, because the records can also decrease errors and reduce health costs, according to a majority of respondents.

Overall, 60% of 2,153 respondents said the benefits of electronic medical records outweigh the risks; 63% said electronic records can significantly decrease the frequency of medical errors, 55% said they can significantly reduce costs, and 51% said they make it more difficult to ensure patients’ privacy.

A couple other interesting findings: 76% of respondents are confident that the doctor always “has an accurate and complete picture” of their prior medical history (we suspect a survey of docs would yield a less confident response to this one). And only 1% of respondents said they use a personal health record stored on the Internet — demonstrating that there’s plenty of room for growth in the ambitious personal-health Microsoft and Google are working on.

Health Blog Question of the Day: Do the benefits of electronic medical records outweigh the privacy risk? If so, what can be done to get more doctors to go electronic?

Balanced hospital budgets approved by South West LHIN (Ontario)

LONDON, ON, May 1 /CNW/ -
The South West Local Health Integration Network (LHIN) Board of Directors reviewed and approved Hospital Service Accountability Agreements (H-SAAs) for 16 hospitals yesterday for the fiscal year 2008/09 and 2009/10.

The following hospitals submitted balanced budgets for 2008/09 and 2009/10:
• Alexandra Hospital (Ingersoll)
• Alexandra Marine & General Hospital (Goderich)
• Hanover District Hospital
• Huron Perth Healthcare Alliance: Clinton Public Hospital, Seaforth Community Hospital, St. Marys Memorial Hospital, Stratford General Hospital
• Listowel Wingham Hospitals Alliance: Listowel Hospital and Wingham Hospital
• London Health Sciences Centre
• Middlesex Hospital Alliance: Four Counties Health Services (Newbury)
• South Bruce Grey Health Centre
• South Huron Hospital Association (Exeter)
• St. Joseph's Health Care, London
• St. Thomas-Elgin General Hospital
• Woodstock Private Hospital

The Board extended the budget negotiation period for four hospitals:
• Grey Bruce Health Services
• Middlesex Hospital Alliance: Strathroy Middlesex General Hospital
• Tillsonburg District Memorial Hospital
• Woodstock General Hospital

The review of H-SAAs at yesterday's Board meeting marks another step in an evolving process that began last fall when hospitals submitted the first draft of their annual plans. The South West LHIN will now work with the 16 hospitals to implement their annual plans and introduce a process to further assist the four hospitals that have not yet balanced their budgets.

"The completion of 16 agreements is an important milestone for our LHIN and for the communities served by our hospitals," says Tony Woolgar, chief executive officer of the South West LHIN. "We are continuing to work closely with the four hospitals that have not yet balanced their budgets and we are confident that they will be able to do so.

"The process for hospital budget development and approval this year is quite different than in the past and our hospitals have risen to the challenge, recognizing that it provides a solid foundation for system planning and performance improvement as we move forward," adds Woolgar.

QUICK FACTS

The 2008-2010 Hospital Service Accountability Agreement (H-SAA) process marks the first hospital budget negotiation between Ontario's 14 LHINs and hospitals. Hospitals are required to balance their budgets under the Local Health System Integration Act, 2006. Signed by the boards of directors of both hospitals and their LHIN, H-SAAs hold hospitals accountable for operating within a balanced budget and maintaining agreed upon service levels.

Ontario's LHINs have an accountability agreement with the Ministry of Health and Long-Term Care. For information on the South West LHIN's Ministry-LHIN Accountability Agreement, visit the "Accountability" section under "About our LHIN" at www.southwestlhin.on.ca

The South West Local Health Integration Network (LHIN) is a crown agency responsible for planning, integrating and funding more than 150 health service providers, including hospitals, long-term care homes, mental health and addictions agencies, community support services, community health centres, and the South West CCAC. Established under the Local Health System Integration Act, 2006, as one of 14 LHINs across Ontario, the South West LHIN operates an annual health care budget of $1.8 billion. The South West LHIN covers an area from Lake Erie to the Bruce Peninsula and is home to almost one million people.

No immediate cash for the Calgary Health Region says Premier Ed Stelmach

May 07, 2008

CALGARY — The urgent need for cash outlined by the Calgary Health Region is also being experienced in other Alberta cities, says Alberta Premier Ed Stelmach.

Stelmach was in Calgary on Tuesday and received a tour of the new Alberta Children's Hospital from chairman Jack Davis.

"It was in September of 2000 that then minister of Infrastructure Ed Stelmach phoned the Calgary Health Region and said the funds for the new children's hospital would be made available," said Davis.

"So we were very pleased today to be able to tour the premier and his wife around the children's hospital to see what that commitment's resulted in."

Davis has been looking for about $190 million from the province to deal with the dire problems he outlined during the last election campaign.

Calgary's three main hospitals had been struggling with seriously overcrowded emergency rooms, forcing patients to queue in hallways on stretchers.

Stelmach told reporters that he isn't making any commitments until after Health Minister Ron Liepert finishes his review of the health-care system. He said it's not just Calgary that is feeling the pinch.

"There are unique issues in every regional health authority in the province of Alberta," conceded Stelmach.

"If you go to Fort McMurray, you will hear Fort McMurray say you are extracting our resources and you're not returning enough here," he said. "If you go to Grande Prairie, it's the same issues. Every region has the same issue that we have in Calgary."

Both Liepert and Stelmach have stressed that there must be changes to get a handle on spiralling costs that have hit $13 billion. That means the province is spending a third of its budget on health care, but there are still long wait times and shortages of doctors and nurses.

"We have to find a way to make is sustainable and everybody tells us that if you are going to be increasing your budgets year by year and eventually you double it," he said. "If you double it, which department do you take out?"

Stelmach has said such a financial burden will eventually hinder the government from moving on other priority areas such as education. He said there is a reason the Capital Health Regional in Edmonton receives $110 million a year more than Calgary.

"The formula is quite complex. It looks at the socio-economic structure of the region," he explained. "There are differences in aboriginal community service and seniors. There are a whole bunch of different factors into the formula."

Canadian Press

Will Pan Canadian standards for our electronic health records leave Canadian snow birds out in the cold?

Industry leaders from Canada Health Infoway (Infoway), Canadian Healthcare Information Technology Trade Association (CHITTA, the Health Division of Information Technology Association of Canada (ITAC)), and the Association of Health Technology Industry (AITS) have formed a task force to accelerate and promote the transition to a new set of pan-Canadian health information technology standards – intended to accelerate electronic health records in Canada.

What?

The task force will collaboratively work to promote the adoption of pan-Canadian standards, especially with point of service systems, by engaging clinicians, health care providers and vendors. Involving these stakeholders will support the planning required to ensure the interoperable electronic health record (iEHR) is leveraged and the adoption of pan-Canadian standards is accelerated.

So . . . On the one hand: Infoway and partners have formed a task force with a mandate for a new set of pan-Canadian health information technology standards. But why just “pan-Canadian”? It sounds like future Snow Birds could be left out in the cold when they need care during their winter sojourns in warmer climates. They will be able to get their money but with their Canadian standards may not be able to get their blood type. (Is it A negative or O negative?)

On the other hand: Infoway acknowledges that Microsoft and Google will be offering (with considerable clout) personal health records to Canadian consumers. See Infoway has personal health record concerns from HealthEdition.com

Our inventive IT industries [most of them multi-nationals] will hopefully carry the day and ensure a global standard that also works for Canadians. Maybe a "Panstandard?"

The Impact of the Electronic Health Record on Patient Safety: An Alberta Perspective

by Patrick Binns

Alberta is at the leading edge in developing its electronic health record (EHR), a provincial initiative to provide healthcare providers with immediate access to a patient's medication history and laboratory test results, regardless of where they are in the province, or where the patient's drugs or other treatments were ordered. The Alberta EHR was launched in October 2003. So far 6,000 healthcare providers have voluntarily signed on to use it, and benefits to patient safety have been reported. The EHR is an important part of healthcare renewal that is required to improve patient safety. Read the whole article by clicking here.

Wal-Mart partners with hospitals to rapidly expand in-store clinics

Analysts say the giant retailer wants the good will a trusted hospital name can provide. Hospitals, meanwhile, say they don't intend to compete with physicians.

By Pamela Lewis Dolan, AMNews staff. Feb. 25, 2008.

---

As big-name national retailers and pharmacy chains continue to open in-store clinics, a familiar face soon may enter the fray as well -- your local hospital.

Wal-Mart recently announced plans to partner with community hospitals across the country to open up 400 new retail clinics inside its stores by 2010, in addition to the 55 it already houses. Thirteen of those are owned and operated by hospital systems.

The rebranded "Clinic at Wal-Mart" also will sport the name of the partnering health system providing the nurse practitioners and physician assistants dispensing care, as well as the doctors overseeing them. But Wal-Mart would standardize the clinics so they have a similar look and feel, such as having each clinic post a price list and keep similar hours.

To continue reading this report please click here.

A First Comparison of Google Health and MS HealthVault

[Posted (on his own blog) by Vince Kuraitis on March 2, 2008. Intro only. To see the complete entry click on the title above.]

While details are thin, here’s a first pass at comparing and contrasting Google Health (GH) and Microsoft HealthVault (HV). Overall, there are many common features, some differences, and many common challenges between these two platforms.

A High Level Comparison
Google Health and Microsoft HealthVault
Personal Health Information (PHI) Platforms

There’s still not much information available about the specifics of GH, although they did release sketchy information on the Official Google Blog. I’ll comment on a few of the particulars.

Commonalities

Both are patient controlled — data is released only with patient permission.
For more, click here.

Google vs. Wal-Mart in Electronic Health Record Battle for Consumers

The most powerful consumer Internet company in the world and the world's most powerful consumer retailer seek to control consumer WEB access to the powerful health care industry.

Microsoft vs. Google for consumer health care dominance is the typical battle cry.

Nevertheless, in the fight to “consumerize” health care via technology, major U.S. employers are powerful stakeholders in their own rights, as they battle to control medical insurance costs for their workers on a daily basis.

How about Dr. Google vs. Dr. Wal-Mart? Click on the title and read on . . .

Canada Takes a Closer Look at Personal Health Records

April 17, 2008 – As the Internet has enabled consumers to manage important aspects of their personal lives from the relative comfort of their home, it is no surprise that Canadians are becoming increasingly intrigued by the prospect of being able to view and manage their health information using emerging personal health records (PHR) technologies.

Recent announcements by major players in the IT industry suggest such capabilities are just around the corner. Recognizing developments in this area are moving quickly, Canada’s federal, provincial and territorial health ministries have expressed support for Canada Health Infoway’s (Infoway) plan to discuss personal health record solutions with interested vendors and to explore how these technologies could be made available to Canadians in a secure manner.

According to Richard Alvarez, President and CEO of Canada Health Infoway, the federally-funded, independent, not-for-profit organization that is leading the adoption of electronic health records across Canada: providing Canadians and their health care providers with appropriate and secure access to their health information has been Infoway’s goal from the onset. The agency wants to ensure appropriate level of trust to protect the privacy and security of health information.

The government anticipates that the onset of personal health record solutions can accelerate the reality of electronic health records.

Microsoft, Wal-Mart and Google have been actively developing this technology. In February, 2008, Google launched a pilot with a medical institution committed to giving patients access to their own medical records: The Cleveland Clinic. A large academic medical center, Cleveland is one of the first partners to integrate on the Google platform.

For more on the Google initiatives see:

Google Conversations about Health & Records

A pilot with the Cleveland Clinic for health information access